Clinical Challenges and Images in GI
Article Outline
- Question
- Answer to the Clinical Challenges and Image of the Month in GI Question: Image 1 (page 1379): Yersinia enterocolitica Mesenteric Adenitis and Terminal Ileitis
- References
- Copyright
Question
A 53-year-old man with diabetes mellitus presented with right lower quadrant abdominal pain and fever, followed by diarrhea. He had had an appendicectomy 22 years previously. On examination, he was febrile with a temperature of 37.8°C, pain localized to the right lower abdomen, and mild tenderness in the same area. His laboratory studies showed white blood cell count of 15,400/mm3 with 86% neutrophils and a C-reactive protein of 11.6 mg/dL. Colonoscopy showed a large, irregularly shaped deep ulceration on the terminal ileum (Figure A). Abdominal computed tomography revealed the mass 6 cm in diameter along the border of the ileocecal region, which was thought to be mesenteric in origin (Figure B). What is the most likely diagnosis?
Look on page 1659 for the answer and the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Answer to the Clinical Challenges and Image of the Month in GI Question: Image 1 (page 1379): Yersinia enterocolitica Mesenteric Adenitis and Terminal Ileitis
The presentation and clinical studies supported a differential diagnosis of malignancy, Crohn’s disease, as well as infectious mesenteric adenitis. Histological findings from colonic biopsies revealed severe acute colitis with neutrophils infiltrations, acute ulceration, and necrosis. Stool cultures yielded growth of Yersinia enterocolitica. The patient was treated with antibiotics based on sensitivity test. His symptoms resolved promptly with medical therapy alone. Twenty-four days later, follow-up colonoscopy showed complete healing of the ulcer. The patient recovered completely and was discharged without surgery. Two months later, abdominal CT showed a clear regression of enlarged mass. Retrospectively, the CT findings were compatible with mesenteric adenitis.
Infection with Y enterocolitica is usually a benign, self-limited disorder characterized by fever, diarrhea, abdominal pain, mesenteric adenitis, erythema nodosum, or other immunologic manifestations. Emergency intestinal resections have been performed in some patients, however, and some have died of fulminant disease. Yersinia septicemia can occur during acute infection, particularly infants and those with impaired immune defenses or iron-overload states.1, 2 Y enterocolitica usually invades via Peyer’s patches, causing microabscesses, and ulceration of the overlying epithelium. The organism commonly involves the terminal ileum and can invade mesenteric nodes.3 Mesenteric adenities, which is the most common clinical manifestation, causes a pseudoappendicular syndrome. However, there have been very few reports of Yersinia infection presenting as an abdominal mass.4 Although rare, as in our case, it can present with an abdominal mass caused by pathologic enlargement of one or more of the mesenteric lymph nodes in the ileocecal region. Yersinia infection should be considered in patients with a right lower abdominal mass.
References
- . Yersinia enteritis and enterocolitis: gastroenterological aspects. Gastroenterology. 1977;72:220–227
- . Yersinia species, including plague. In: Mandell GL, Bennett JE, Dolin R editor. Principles and practice of infectious diseases. 6th ed. Philadelphia: Elsevier; 2005;p. 2691–2700Vol. 2
- . Yersinia enterocolitica infection in a patient with hemachromatosis masquerading as proximal colon cancer with liver metastases: report of a case. Dis Colon Rectum. 2005;48:390–392
- . A right lower abdominal mass due to Yersinia mesenteric lymphadenitis. Pediatr Radiol. 1994;24:70–71
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PII: S0016-5085(06)02197-4
doi:10.1053/j.gastro.2006.09.029
© 2006 AGA Institute. Published by Elsevier Inc. All rights reserved.
